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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON$ CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address + City �4f L`/ Lot Size/Acreage Owner's Name C f r N w C � Address 1�,e We_ Phone .3� Corllrattvr��L -•-�um 'r`� Address Q /4` c7 f• • r License No.-. ..A� Phone 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Ll Out of Service Well L1 PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER Q Monitoring Well {� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom [I Manteca Dia. of Well Excavation Dia. of Wel! Casing Cl Domestic/Private ❑ Gravel Pack E-rTracy Type of Casing- Specifications_ - -- CI Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump - — H.P. / State Work Done Well Destruction 0 Well Diameter — Sealing Material & Depth Xyi Filler Material & Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) 1 Installation will serve: Residence— Commercial— Other A Number of living units: Number of bedrooms A`V Character of soil to a depth of 3 feet: —WatP*YMIENTi SEPTIC TANK O Type/Mfg Capacity Met PKG. TREATMENT PLT. Ll � MAbkW0YX 1) Distance to nearest: Well foundation Property l�i R1R p � 2 LEACHING LINE Cl No. & Length of lines Total lengttpo y FILTER BED n Distance to nearest: Well Foundation OIVjSkON Z SEEPAGE PITS 11 Depth Sire Number l SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County �- Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mu call for all required i�nspsections. Complete drawing on reverse side. Signed ��rr /tea.[ .� Title: P r Date: X�, - FOR DEPARTMENT USE ONLY Application Accepted by Date Area -- Pit or Grout Inspection by Date Final Inspection by A2 Date 3 �� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin O Box 2009, Stkn, CA 95201 FE. AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY OATE PERMIT'NO. INF�O1 �[�-^ [� �r,,� 9 9 . EH 13-24 IAEY.t/x W A� �'�.�� / 6] , Q� ��7 V L.�v 211 EH 14.26